RJ 


UC-NRLF 


Pt, 


00 
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What  Is  Malnutrition? 

Hundreds  of  thousands  of  American 
children  are  undernourished 


By 
LYDIA  ROBERTS 


litfren's  Year  Follow-up  Series  No.  1  Bureau  Publication  No.  59 

U.  S.  Department  of  Labor 

Children's  Bureau 


WHAT  IS  MALNUTRITION? 

Malnutrition  in  children  has  at  last  begun  to  receive  the  attention, 
it  deserves.  Articles  concerning  it  are  appearing  in  medical  jour- 
nals, popular  magazines,  and  newspapers;  and  a  variety  of  agencies 
are  being  set  at  work  to  combat  it. 

It  is  important  that  information  on  this  subject  should  reach  par- 
ents, teachers,  social  workers,  and  all  others  responsible  for  the  wel- 
fare of  children.  In  order  to  insure  this,  it  has  seemed  worth  while 
to  summarize  in  bulletin  form  the  most  important  facts  concerning 
the  nature,  extent^ causes,  effects,  and  treatment  of  this  condition. 

SIGNS  AND  SYMPTOMS  OF  MALNUTRITION. 

The  first  question  which  naturally  arises  is:  What^Js^jria  1  mi tr\ - 
tion?  Is  it  an  infectious  disease  like  measles  or  whooping  cough 
which  runs  its  course  and  then  is  over?  Unfortunately  not,  other- 
wise steps  would  long  ago  have  been  taken  to  control  it.  Neither  is 
it  a  disease  like  gout  or  rheumatism  which  causes  sufficient  pain  to 
demand  attention  and  treatment.  It  is,  in  fact,  not  a  disease  at  all, 
but,  as  Dr.  George  Newman,  chief  medical  officer  of  the  board  of 
education  (England  and  Wales),  ©  *  well  expresses  it,  "a  low  con- 
dition of  health  and  body  substance.  It  is  measurable  not  only  by 
height,  weight,  and  robustness,  but  by  many  other  signs  and  symp^ 
t6ms."  A  description  of  these  u  signs  and  aymploins  "  found  in  the 
undernourished  child  will  furnish  a  better  idea  of  the  meaning  of  the 
term  than  can  any  attempt  at  formal  definition.  The  picture  will  be 
even  clearer  if  its  opposite — a  healthy,  well-nourished  child — be  first 
described. 

A  well-nourished  child,  first  of  all,  measures  up  to  racial  and  fam- 
ily standards  of  his  age  in  height  and  weight.  He  has  good  color, 
bright  eyes — no  blue  or  dark  circles  underneath  them — and  smooth, 
glossy  hair.  His  carriage  is  good,  his  step  elastic,  his  flesh  firm,  and 
his  muscles  well-developed.  In  disposition  he  is  usually  happy  and 
good-natured ;  he  is  brim  full  of  life  and  animal  spirits  and  is  con- 
stantly active  both  physically  and  mentally.  His  sleep  is  sound,  his 
appetite  and  digestion  good,  his  bowels  regular.  He  is,  in  short,  what 
nat  ure  meant  him  to  be  before  anything  else — a  happy,  healthy  young 
animal. 

A  malnourished  child  lacks  several  or  all  of  these  characteristics  of 
a  normal  child,  depending  on  the  degree  of  undernutrition.  He  is 

1  The  circlnJ  figures  used  throughout  refer  to  corresponding  figures  in  the  list  of  refer- 
ences found  on  pp.  19  to  20. 

(3) 


.-'  <  0-7  i  ft 


usually  tlii)  i,  I  nit  HIM  be  fat  and  flabby  instead.  His  skin  may  have 
a  pale,  delicate,  waxlike  look,  or  be  sallow,  muddy,  even  pasty  or 
"  earthy "  in  appearance.  There  are  usually  dark  hollows  or  blue 
circles  underneath  his  eyes,  and  the  mucous  membrane  inside  his 
eyelids  and  in  his  mouth  is  often  pale  and  colorless.  His  hair  may 
be  rough — like  that  often  seen  in  poorly  cared  for  farm  animals — 
his  tongue  coated,  and  his  bowels  constipated.  His  skin  seems  loose, 
his  flesh  is  flabby,  and  his  muscles  are  undeveloped.  Because  of  the 
lack  of  a  muscular  tone,  his  shoulders  are  usually  rounded,  sometimes 
protruding  to  such  an  extent  as  to  make  the  deformity  known  as 
"  wings  " ;  his  chest  is  flat  and  narrow.  Decayed  teeth,  adenoids,  en- 
larged or  diseased  tonsils  may  also  be  present.  0 

The  animal  spirits  natural  to  all  healthy  young  are  apt  to  be  lack- 
ing in  the  undernourished  child.  He  may  be  listless  in  play  and 
work,  will  probably  tire  easily,  not  care  to  romp  and  play  like  other 
children,  and  will  often  be  regarded  as  lazy.  There  is  likely  to  be  a 
lack  of  mental  vigor  also.  Little  power  of  concentration  and  atten- 
tion, and  absence  of  a  child's  natural  inquisitiveness  and  mental  alert- 
ness are  his  common  characteristics.  The  expression  of  his  eyes  and 
of  the  entire  face  is  often  lifeless  and  dull.  In  disposition,  he  may 
be  extremely  irritable  and  difficult  to  manage,  and  he  is  often  abnor- 
mally afraid  of  strangers.  He  may  be  nervous,  restless,  fidgety,  and 
will  probably  sleep  lightly  and  be  "  finicky  "  about  his  food. 

Such,  then,  are  some  of  the  "  signs  and  symptoms  "  which  may  dis- 
tinguish a  malnourished  child  from  a  well-nourished  one.  It  is  easy 
to  see  that  malnutrition  is  a  relative  term.  There  are  all  degrees  of 
undernutrition — from  severe  cases  exhibiting  practically  every  symp- 
tom described  above,  to  the  ones  which,  though  they  seem  to  lack 
definite  symptoms,  still  give  the  general  impression  of  not  being  just 
normal.  In  actual  practice,  however,  children  are  called  malnour- 
ished only  when  one  or  more  of  the  various  symptoms  have  become 
quite  marked,  particularly  underweight  for  height  and  flabbiness  of 
flesh  and  muscles.  Since  underweight  is  an  almost  certain  result  of 
faulty  nutrition,  it  has  become  the  custom  of  many  physicians  to  class 
children  as  malnourished  by  this  one  symptom  alone.  Dr.  Emerson, 
who  was  one  of  the  first  to  direct  our  attention  to  the  treatment  of 
undernourished  children,  has  called  any  child  malnourished  who  is 
habitually  10  per  cent  underweight  for  height.  0  In  a  very  recent 
study  he  is  using  7  per  cent  as  the  standard.  0  Dr.  Holt  considers 
10  per  cent  underweight  for  height  from  6  to  10  years  and  12  per 
cent  from  11  to  16  years  indications  of  undernutrition.  0  He 
believes  the  annual  rate  of  increase  in  weight  and  height,  however, 
to  be  even  more  important.  0  0  Any  child,  therefore,  who  is 
markedly  underweight  for  his  height  or  who  does  not  gain  at  the 
normal  rate  can  be  safely  put  into  the  malnourished  group.  Other 


defects  will  usually  confirm  the  decision.  Dr.  Emerson  finds  an 
avrnige  of  five  physical  defects  in  a  malnourished  child  to  one  in  a 
swell-nourished  one. 

There  can  be  no  question  that  children  10  per  cent  below  normal 
weight  for  their  height  should  be  classed  as  malnourished,  for,  as 
Dr.  Emerson  says,  "  Children  do  not  become  underweight  to  this  de- 
gree except  for  adequate  causes."  (D  The  only  question  is,  Should 
we  stop  there?  In  New  York  City,  at  least,  there  are  60  to  70  chil- 
dren out  of  every  hundred — as  figures  given  later  will  show — who  are 
not  underweight  to  the  extent  of  10  per  cent,  but  who  are,  neverthe- 
less, below  par  in  one  or  more  respects.  Inquiry  into  the  living 
habits  of  these  children  almost  always  reveals  a  faulty  diet  or  other- 
wise defective  health  program.  That  they  are  not  underweight  may 
be  due  to  good  feeding  during  infancy  or  unusually  resistant  bodies ; 
for  it  often  takes  considerable  time  before  the  results  of  bad  living 
show  themselves  in  loss  of  weight,  anemia,  and  other  definite  symp- 
toms. It  would  be  worse  than  folly,  surely,  to  wait  for  a  loss  of 
weight  to  tell  us  that  such  children  are  being  undernourished. 
Would  it  not  be  wise,  in  fact,  to  regard  them  as  malnourished  in 
a  less  degree  and  consider  them  safe  only  when  they  are  known  to  be 
on  a  suitable  diet  and  living  a  normal  child's  life?  These  are  the  ones 
whom  a  little  influence  for  good  or  bad  would  easily  push  up  into  the 
excellent  group  or  down  into  the  malnourished  one.  Now  is  the 
time  to  see  that  they  get  pushed  in  the  right  direction.  Is  it  too 
high  a  standard  to  say  that  we  aim  to  put  all  children  in  the  ex- 
cellent group  ? 

EXTENT  OF  MALNUTRITION. 

Knowing  the  character  of  malnutrition,  the  question  immediately 
follows :  What  is  the  extent  of  this  condition  ?  Are  there  any  consid- 
erable numbers  of  malnourished  children  in  our  own  and  other 
countries?  And  is  their  number  decreasing  or  increasing? 

In  France,  Belgium,  and  other  countries  of  the  war  zone  the  ques- 
tion  can  have  but  one  answer.  In  spite  of  stupendous  efforts  to  pro- 
tect the  young  the  shortage  of  food  and  other  conditions  of  war  have 
had  disastrous  effects  on  the  health  of  the  children.  No  statistics  are 
needed  to  show  that  the  number  of  undernourished  children  in  these 
countries  is  appallingly  large. 

In  England  the  condition  is  less  serious,  though  grave  enough  to 
demand  attention.  Dr.  Newman  in  his  1915  and  1917  reports 
©  ©  concludes  that  fully  10  per  cent  of  the  school  children  are 
malnourished.  So  large  a  number  is  a  matter  of  grave  con- 
cern. Compared  with  the  numbers  for  previous  years,  however,  the 
figures  show  that  in  spite  of  the  war,  the  number  of  seriously  under- 


nourished  children  has  actually  decreased.  On  the  other  hand,  the 
number  of  children  in  the  best  nutritive  condition  as  opposed  to  fail- 
has  also  diminished.  Medical  officers  attribute  the  decrease  of 
marked  malnutrition  to  the  higher  wages  which  have  made  the  pur- 
chase of  an  adequate  diet  possible.  ®  The  decrease  in  good 
nutrition  they  believe  is  explained  by  the  anxiety  of  mothers  to  fall 
in  with  the  voluntary  rationing  of  the  food  controller.  Speaking 
generally,  however,  the  consensus  of  opinion  among  English  medical 
officers  is  that  the  children  of  their  schools  are,  on  the  whole,  in  a 
better-nourished  condition  than  they  were  before  the  war.  0 

In  our  own  country  the  figures  are  not  so  gratifying.  ©  We 
have  no  method  of  obtaining  data  for  the  whole  country  as  has 
England,  so  results  of  certain  typical  investigations  are  our  only 
guides.  One  of  the  most  recent  investigations  @  was  made  in 
March,  1918,  by  the  bureau  of  child  hygiene  of  New  York  City.  Of 
171,661  school  children  from  the  borough  of  Manhattan  who  were 
examined,  the  following  results  were  obtained:  Grade  I  (excellent), 
17.3  per  cent;  Grade  II  (passable),  61.1  per  cent;  Grade  III  (poor), 
18.5  per  cent;  Grade  IV  (very  poor),  3.1  per  cent. 

A  number  of  scales  for  grading  physical  examinations  of  children  have  been 
devised  and  used.  The  Dunfermline  scale,  (12)  @  originated  by  Dr.  Mc- 
Kenzie,  of  Dunfermline,  Scotland,  was  adopted  by  the  bureau  of  child  hygiene 
of  New  York  City  a  few  years  back  and  is  the  one  now  used  generally  through- 
out the  country.  This  scale  divides  children  into  four  classes: 

I.  Excellent. — The  state  of  nutrition  of  a  child  of  superior  healthy  condition. 
(The  perfect,  well-nourished  child  described  above.) 

II.  Passable. — Children  falling  just   short  of  excellent.     (Sometimes  called 
fair,  or  good,  or  normal.) 

III.  Poor. — Children  requiring  supervision. 

IV.  Very  poor. — Children  requiring  medical  attention. 

The  ones  falling  into  Classes  III  and  IV  are  usually  considered  as  cases  of 
malnutrition. 

The  value  of  this  scale  lies  in  the  fact  that  it  makes  grading  easy,  because 
in  Groups  III  and  IV  it  names  something  definite  to  be  done  to  a  child,  and  in 
Group  I  it  explicitly  states  that  a  child  so  graded  is  not  merely  excellent  com- 
pared with  others  of  a  group,  but  is  one  who  would  be  considered  excellent 
anywhere.  In  making  the  classification,  other  factors  than  weight  are,  of 
course,  considered.  The  general  appearance  of  the  child,  the  condition  of  the 
skin  and  subcutaneous  tissue,  the  muscular  tone  and  development,  the  state  of 
the  mucous  membrane,  the  vigor  or  listlessness  which  may  appear  in  the 
child's  facial  expression,  carriage,  movements,  voice,  interest,  and  attention, 
all  contribute  to  the  decision. 

Even  with  such  a  grading  system,  however,  in  which  the  classes  are  fairly 
well  defined,  it  could  not  be  expected  that  any  two  examiners  would  necessarily 
classify  a  given  group  of  children  exactly  the  same.  So  long  as  the  work  is 
done  by  human  beings,  the  personal  equation  will  enter  in.  And  yet  in  a  test 
application  of  this  scale  in  New  York  City  it  was  found  that  physicians  agree 
on  the  state  of  nutrition  as  well  as,  or  better  than,  they  do  on  even  such  common 
defects  as  tonsils  and  bad  teeth.  The  use  of  the  scale  has  been  criticized, 


however,  and  it  must  be  admitted  that  the  grades  are  apt  to  signify  very 
different  things,  depending  on  the  examiner.  It  was  found  in  New  York  City, 
for  instance,  that  physicians  in  certain  sections  had  become  so  accustomed  to 
malnutrition  that  they  had  come  to  regard  it  as  a  racial  or  local  tyi»<>, 
iiud  si nco  they  found  no  children  belonging  in  Group  I  they  hud  used  the 
scale  merely  to  show  degrees  of  malnutrition.  The  fact  that  such  grading  may 
occur  hardly  seems  sufficient  ground  for  abolishing  the  scale  entirely,  for  it 
n>n  a  inly  serves  a  purpose.  It  would  instead  seem  wiser  to  make  sure  that 
all  examining  physicians  are  actually  familiar  with  the  physically  superior 
tyi>e:  that  they  know  the  scale,  the  requirements  for  the  different  grades, 
ami  understand  fully  that  the  standards  are  to  be  applied  as  absolute  not 
relative  ones.  Other  classifications  are  sometimes  used,  as  good,  fair,  poor, 
or  a  five-grade  scale  of  excellent,  good,  fair,  poor,  and  very  poor.  It  matters 
little  what  scale  is  used,  however,  if  the  standards  for  each  grade  are  well  de- 
fined and  these  standards  strictly  adhered  to  in  the  grading.  The  advisability 
of  grading  all  children  instead  of  disregarding  all  but  the  markedly  under- 
weight ones  is  evident. 

The  bureau  of  child  hygiene  believed  that  these  figures  could  be 
safely  assumed  as  applicable  to  the  city  as  a  whole.  This  being  so, 
New  York's  1,000,000  school  children  would  be  distributed  about  as 
follows:  Normal  as  regards  nutrition,  173,000;  passable,  611,000;  seri- 
ously undernourished,  216,000.  According  to  Dr.  Josephine  Baker, 
@  this  last  number  is  a  decided  increase  over  those  for  previous 
years.  She  gives  the  proportion  of  malnourished  school  children 
as  5  per  cent  in  1914,  6  per  cent  in  1915,  12  per  cent  in  1916, 
and  21  per  cent  in  1917.  With  such  conditions  revealed — with  over 
200,000  malnourished  children  in  their  schools,  and  with  the  number 
rapidly  increasing — is  it  any  wonder  that  New  York  physicians 
and  child  welfare  agencies  have  become  aroused  to  the  fact  that  it 
behooves  them  to  do  something  about  it? 

These  figures  are  for  New  York  City.  To  what  extent  they  are 
applicable  to  the  country  at  large  we  can  only  surmise;  but  we  can 
safely  conclude  that  the  estimate  so  frequently  made  that  10  per 
cent  of  the  children  in  our  country  are  suffering  from  malnutrition 
is  far  too  low.  The  estimate  given  by  Dr.  Wood  ©  that  between 
15  and  25  per  cent  of  our  school  children  (3,000,000  to  5,000,000)  are 
undernourished  is  probably  much  nearer  the  truth. 

CAUSES  OF  MALNUTRITION. 

The  most  important  question  to  consider  in  regard  to  malnutrition 
is,  What  causes  it?  Why  are  so  few  children  in  the  excellent  group? 
Why  are  so  many  distinctly  malnourished  and  a  still  larger  number 
much  below  par?  Are  a  certain  few  "predestined"  to  be  physically 
fit  and  others  doomed  by  inheritance  to  be  inferior  to  a  greater  or 
less  degree? 

It  is  easy  to  blame  heredity,  and  there  can  be  no  question  that  poor 
inheritance  may  handicap  a  child's  development.  Physicians  are 


8 

generally  agreed,  however,  that  it  is,  after  all,  responsible  for  but  a 
very  minor  part  of  malnutrition.  The  majority  of  children  are  born 
healthy.  Given  this  start,  with  proper  surroundings  and  nur- 
ture, they  should  develop  normally  into  healthy,  well-nourished 
children.  That  this  happens  in  so  few  cases  is  definite  proof  that 
there  is  something  wrong  with  the  health  program,  resulting  in  faulty 
health  habits.  0  Failure  to  provide  a  child  with  any  one  or  more 
of  the  necessary  conditions  for  normal  growth  may  result  in  malnu- 
trition. The  most  important  causes  of  this  condition  may,  therefore, 
be  readily  given. 

SPECIFIC  CAUSES. 

Diet. — Insufficient  or  unsuitable  food  and  drink,  such  as  tea  and 
coffee  instead  of  milk,  is  generally  conceded  to  be  the  chief  cause  of 
undernutrition.  The  first  requirement  of  a  growing  child  is  food. 
Every  movement  his  body  makes,  every  bit  of  work  it  does,  requires 
energy,  and  this  energy  must  be  furnished  by  the  food  he  eats.  If 
the  food  supply  is  insufficient,  the  body  itself  is  burned  to  provide 
the  energy,  and  loss  of  weight  results.  It  is  essential,  therefore, 
that  the  diet  of  a  growing  child  should  be,  first  of  all,  generous  in 
amount.  An  insufficient  and  inadequate  breakfast  of  bread  and 
coffee,  whether  or  not  the  midday  meal  is  adequate,  practically  always 
means  too  little  total  food,  even  though  a  hearty  supper  may  be  eaten. 
Indulgence  in  sweets  and  highly  seasoned  foods,  habitual  eating  be- 
tween meals,  late  hours,  unventilated  sleeping  rooms,  and  lack  of 
exercise  may  all  result  in  a  "  finicky  "  appetite  and  thus  in  the  taking 
of  too  little  food.  Whenever  the  food  eaten  habitually  falls  below 
the  actual  need,  no  matter  for  what  reason,  malnutrition  is  the  un- 
failing consequence. 

A  diet  inadequate  in  the  kind  of  food  has  equally  disastrous  re- 
sults. To  be  well  nourished,  a  child  must  have  every  day  some  body- 
building material,  or  protein,  to  help  form  his  -muscles,  his  blood,  his 
heart,  his  lungs,  his  brain,  and  all  other  living  parts  of  the  body. 
Without  it  his  muscles  can  not  develop  normally  nor  his  organs  be  in 
the  best  condition.  Certain  proteins  of  animal  origin — those  of  milk, 
eggs,  and  meat — are  more  valuable  for  growth  than  are  those  of 
cereals,  beans,  peas,  and  vegetables.  A  liberal  amount  of  the  child's 
"building  material,"  therefore,  should  be  furnished  by  foods  of 
animal  origin.  Failure  to  supply  these  in  sufficient  amounts  may 
result  in  undernourishment. 

Another  specific  need  of  the  child's  body  is  for  minerals.  He  must 
have  plenty  of  lime  to  build  sound  bones  and  teeth,  iron  to  make  red 
blood,  and  other  minerals  for  just  as  definite  uses.  Without  suitable 
amounts  of  lime  and  phosphorus,  his  bones  will  surely  be  spongy 
and  his  teeth  defective,  while  a  lack  of  iron  causes  anemia.  In  this 


condition  the  blood  has  not  enough  normal  red  corpuscles  to  carry 
sufficient  oxygen  to  the  tissues  to  burn  the  food,  and  loss  of  weight 
follows.  Since  milk  is  about  the  only  liberal  source  of  lime,  and 
since  vegetables,  fruits,  whole  cereals,  and  egg  yolks,  in  addition  to 
milk,  supply  most  of  the  other  minerals,  it  is  readily  seen  that  many 
cases  of  malnutrition  are  caused  by  too  little  of  one  or  more  of  these 
foods. 

In  addition  to  proteins  and  minerals,  a  child's  diet  must  contain 
some  of  the  growth-regulating  substances  commonly  known  as  "  vita- 
mines."  One,  called  water  soluble  B  by  Dr.  McCollum,  ®  is  found 
abundantly  in  vegetables,  fruits,  milk,  and  all  natural  foodstuffs. 
Another  (fat  soluble  A)  ®  is  less  widely  distributed.  It  is  found 
in  liberal  amounts  in  the  fat  of  milk,  egg  yolks,  and  glandular  organs, 
and  in  the  leaves  of  plants.  There  is  little  danger  that  an  ordinary 
diet,  unless  made  up  of  too  purified  foodstuffs,  will  be  lacking  in  the 
first ;  but  it  is  quite  possible  that  many  children  who  have  no  leafy 
vegetables  and  practically  no  milk  or  eggs  may  fail  to  grow  nor- 
mally because  of  an  insufficient  amount  of  the  fat  soluble  vitamine. 
Without  fairly  liberal  amounts  of  milk,  leafy  vegetables,  and  eggs, 
therefore,  the  diet  can  hardly  fail  to  be  lacking  in  minerals,  growth 
proteins,  and  the  necessary  vitamines.  Malnutrition  of  many  chil- 
dren may  be  laid  to  the  fact  that  they  receive  too  little  of  one  or  more 
of  these  necessary  foods. 

Indigestible  foods  and  faulty  habits  of  eating  may  also  help  to 
cause  undernutrition.  We  have  unquestionably  gone  a  long  way 
when  we  have  provided  a  diet  for  a  child  which  is  ample  in  amount 
and  adequate  in  quality.  In  ideal  feeding,  however,  the  suitability 
of  the  food,  the  hours  of  eating,  and  all  other  food  habits  must  be 
considered  also.  It  must  be  remembered  that  the  child's  digestive 
tract  is  far  from  being  fully  developed  and  should  not,  therefore,  be 
expected  to  take  care  of  all  foods  suitable  for  adult  use  any  more 
than  an  immature  body  can  be  expected  to  do  the  work  of  a  man.  It 
is  important  to  all  his  future  life  that  his  organs  be  not  overtaxed 
nor  his  digestive  system  weakened  while  he  is  young.  To  insure  this 
demands  the  provision  of  simple,  well-cooked,  easily  digested  foods ; 
the  exclusion  of  all  rich,  highly  seasoned,  indigestible  ones;  the  intro- 
duction of  new  foods  only  gradually ;  and  regular,  unhurried  meals, 
with  no  indiscriminate  eating  between  meals.  Failure  to  take  account 
of  these  factors  may  cause  indigestion  and  weakened  powers  of  diges- 
tion and  assimilation.  If  the  body  is  unable  to  use  the  food  pro- 
vided, malnutrition  is  as  certain  as  if  the  diet  were  inadequate  in 
amount.  (For  further  material  on  children's  food,  see  Child  Care, 
pages  11-30;  Milk,  the  Indispensable  Food  for  Children;  and  Feed- 
ing the  Child,  Dodger  No.  8,  published  by  the  Children's  Bureau.) 

Sleep. — Insufficient  sleep  and  other  faulty  health  habits  are  also 
responsible  for  malnutrition.  Experiments  with  undernourished 
children  have  shown  that  even  after  the  diet  has  been  regulated 
122217°— 19 2 


10 

children  do  not  gain  properly  unless  the  hours  of  sleep  are  also 
sufficient  and  regular.  Teachers  and  others  dealing  with  large 
groups  of  children  testify  to  the  fact  that  children  of  early  age  AYJIO 
should  be  in  bed  not  later  than  7  or  8  o'clock  are  retiring  at  9,  10, 
11,  or  even  later.  The  sleep  problem  surely  needs  attacking  as  well 
as  the 'food  problem. 

Fatigue. — The  importance  of  rest,  both  mental  and  physical,  as 
part  of  the  treatment  of  undernourishment  is  plainly  demonstrated 
by  classroom  work  in  the  schools.  Certain  children  will  not  gain 
until  removed  from  school  or  allowed  only  a  half-day  session.  Rest 
periods  of  one-half  to  one  hour  are  found  necessary  to  guard  against 
overfatigue  in  these  chidren.  Complete  physical  relaxation  by  lying 
down  on  the  back  for  even  15  minutes  will  give  better  results  than  a 
longer  time  of  partial  rest.  These  rest  periods  should  be  taken  pref- 
erably before  the  midmorning  lunch  and  the  evening  meal,  and  are 
most  effective  when  combined  with  the  open  window. 

In  addition  to  too  little  sleep  and  fatigue,  lack  of  fresh  outdoor 
air  and  exercise,  constipation,  unhealthful  living  conditions,  and 
undue  excitement  may  also  be  contributing  factors  to  malnutrition. 

Defect  and  disease. — Enlarged  and  diseased  tonsils,  adenoids,  de- 
cayed teeth,  tuberculosis,  and  syphilis  are  also  causes  of  under- 
nutrition.  Adenoids  and  enlarged  tonsils  may  act  in  two  ways. 
They  obstruct  the  free  passage  of  air  to  the  lungs,  thus  limiting  the 
oxidation  of  food  in  the  tissues,  just  as  closing  the  draft  to  a  stove 
keeps  the  fire  from  burning.  Then,  too,  these  abnormal  growths  are 
apt  to  become  diseased,  when  either  their  toxins  may  circulate 
through  the  body  and  prevent  the  building  up  of  tissue  or  even 
destroy  it,  or  secondary  seats  of  focal  infection  may  arise  from  germs 
from  these  diseased  areas  being  carried  by  the  blood  to  distant  parts 
of  the  body.  It  is  not  strange,  therefore,  that  severe  cases  of  mal- 
nutrition are  sometimes  cured  by  merely  removing  these  growths. 

Bad  teeth,  of  course,  may  be  the  result  of  undernutrition,  but  they 
may  in  turn  help  to  cause  it.  They  may  become  sources  of  infection 
similar  to  tonsils  and  adenoids  and  thus  in  the  same  way  cause  tissue 
destruction. 

Probably  the  most  active  agent  in  tearing  down  the  body,  once  it 
attacks  it,  is  tuberculosis.  It  not  only  gradually  destroys  the  organ 
which  is  infected,  but  its  toxins,  like  the  ones  already  mentioned, 
are  so  pernicious  that  only  the  strongest,  most  robust  body  can  with- 
stand them.  It  will  be  seen  later  that  all  these  factors — diseased 
tonsils,  adenoids,  decayed  teeth,  and  tuberculosis — may  be  .results 
as  well  as  causes  of  malnutrition.  When  these  physical  defects  are 
present  they  become  even  more  important  than  food  or  sleep  in  caus- 
ing undernutrition.  No  matter  how  much  wholesome  food  a  child 
eats,  if  he  has  not  enough  oxygen  to  burn  it,  or  if  the  body  is  being 
torn  down  as  fast  as  it  can  be  built  up,  there  is  little  chance  for  him 
even  to  hold  his  own,  much  less  to  gain. 


11 

Children  who  are  victims  of  congenital  syphilis  usually  exhibit 
marked  malnutrition.  The  nutrition  problem,  in  fact,  may  appear  as 
the  most  serious  feature  in  such  cases  and  persist  unhelped  until 
specific  medication  is  used. 

UNDERLYING  CAUSES. 

Poverty. — Before  we  attempt  to  correct  malnutrition,  however,  it 
is  necessary  to  go  still  further  back  and  inquire  into  the  underlying 
causes  of  the  specific  ones.  Why  are  children  insufficiently  fed? 
Why  do  they  have  too  little  sleep?  Why  are  bad  teeth  and  tonsils 
not  attended  to?  The  answer  seems  to  be  that  poverty,  ignorance, 
and  lack  of  parental  control,  singly  or  together,  are  the  responsible 
factors.  Not  long  ago  it  was  customary  to  lay  practically  all  the 
blame  on  poverty.  Recently,'  however,  there  is  a  tendency — because 
of  the  discovery  of  the  importance  of  the  other  two  factors — to  dis- 
regard it  somewhat  as  a  cause,  of  malnutrition.  Either  extreme,  of 
course,  is  wrong.  An  intelligent  woman  can  undoubtedly  come  much 
nearer  providing  an  adequate  diet  for  her  family  on  a  limited  in- 
come than  can  an  ignorant  woman  with  the  same  money — she  may 
even  succeed  where  the  other  fails — but  the  fact  remains  that  there 
is  a  certain  minimum  income  below  which  not  all  the  intelligence  in 
the  world  can  purchase  an  adequate  diet.  It  must  be  remembered, 
too,  that  it  is  poverty  in  a  host  of  cases  which  is  the  real  cause  of 
ignorance.  Had  these  poorer  people  the  means,  would  they  not  in 
fact  move  into  a  better  part  of  town,  live  in  better  houses,  and  pur- 
chase a  better  diet  merely  because  of  the  natural  desire  for  more  and 
varied  foods?  And  would  they  not  naturally  come  into  contact  with 
influences  which  would  to  a  certain  extent  educate  them  ?  Indeed,  if 
we  desire  proof  that  this  is  so,  we  need  but  recall  the  fact  that  in 
England,  even  in  the  midst  of  war,  with  mothers  away  from  home 
working  and  .the  children  more  or  less  neglected,  the  per  cent  of 
markedly  malnourished  children  decreased  rather  than  increased,  as 
it  was  feared  and  expected  would  be  the  case.  This  decrease,  as  be- 
fore mentioned,  is  attributed  by  English  authorities  to  the  high  wages 
which  made  it  possible  for  families  to  have  better  and  more  abundant 
food  and  more  desirable  living  conditions. 

Although  we  have  come  to  know  that  poverty  is  not  the  only 
underlying  cause  of  malnutrition,  we  must  not  forget  after  all  that 
the  first  big  step  toward  removing  large  'numbers  of  children  from 
the  ranks  of  the  undernourished  would  be  to  insure  their  parents  an 
income  considerably  above  the  mere  subsistence  level. 

Ignorance  and  lack  of  parental  control. — Abundant  proofs  that 
ignorance  and  lack  of  parental  control  are  in  many  cases  even  more 
important  factors  than  poverty  are  not  wanting.  Studies  of  home 
conditions  have  shown  that  children  are  insufficiently  fed  because 


12 

parents  are  ignorant  of  what  are  proper  foods,  of  how  to  spend 
their  money  to  get  the  best  return  in  food  value,  of  the  necessity  of 
regular,  unhurried  meals,  of  the  need  of  a  good  breakfast  for  a  grow- 
ing child,  of  the  harmfulness  of  tea  and  coffee  and  the  habit  of 
eating  candy  and  trash  between  meals.  Ignorance,  as  well  as  poverty, 
is  to  blame  for  much  of  the  unhygienic  living;  and  the  same  can  be 
said  of  lack  of  attention  given  to  teeth  and  to  physical  defects.  Re- 
moval of  this  parental  ignorance  without  any  change  in  the  financial 
condition  whatever  will,  in  a  host  of  cases,  be  sufficient  to  effect  the  de- 
sired improvement  in  the  child's  nutrition. 

Even  when  poverty  is  not  a  factor  and  when  ignorance  does  not 
exist  or  has  been  removed,  there  still  remain  many  children  who  are 
undernourished  merely  for  the  lack  of  wise  parental  control.  Even 
when  they  know  better,  a  large  number,  of  parents  allow  their  chil- 
dren to  eat  what  and  when  they  like,  to  live  under  continual  stimula- 
tion and  excitement,  and  to  choose  their  own  time  for  going  to  bed. 
Truly  it  has  become  in  this  respect  to  far  too  great  an  extent  the 
"  age  of  the  child." 

EFFECTS  OF  MALNUTRITION. 

Why  'worry  about  malnourished  children  ?  Many  of  them  manage 
to  keep  alive,  to  pass  through  school,  and  grow  up  to  take  their 
places  in  the  world  as  men  and  women.  Does  it  make  any  difference, 
then,  if  they  are  undernourished  now  ?  It  does,  indeed,  make  a  great 
difference.  "Malnutrition,"  0  says  the  chief  medical  officer  of 
England  after  many  years  of  observation  of  its  effects,  "  is  one  of  tho 
gravest  evils  of  its  [the  child's]  physique.  The  malnourished  child 
tends  to  become  disabled,  and  unemployable,  incapable  of  resisting 
disease  or  withstanding  its  onset  and  process."  Its  evil  effects,  as 
we  shall  see,  are  shown  both  in  the  physical  and  mental  development 
of  the  child. 

PHYSICAL  EFFECTS. 

Stunted  growth,  anemia,  nervousness,  irritability,  and  diminished 
energy  have  already  been  shown  to  be  accompaniments  of  malnutri- 
tion. From  the  standpoint  of  comfortable  living  alone,  these  are 
important.  A  nervous,  restless,  irritable  child  or  adult  is  a  constant 
drain  on  the  life  of  all  his  associates,  and  a  lifeless,  uninterested  one 
is  no  joy  to  himself  nor  to  anyone  else. 

The  results  of  diminished  energy,  however,  are  even  more  far- 
reaching.  The  listless,  inactive,  malnourished  child  who  is  con- 
stantly tired,  who  leans  against  the  schoolhouse  while  his  comrades 
play,  is  father  to  the  man  who  is  handicapped  because  of  low  vitality 
and  a  poorly  developed  body,  and  hence  unable  to  do  his  full  share 
of  the  world's  work.  He  is  the  inefficient  adult,  the  rejected  army 


13 

recruit.  A  proof  of  this  was  shown  at  the  time  of  the  Boer  War, 
when  England  was  shocked  to  learn  that  three  out  of  every  five  men 
who  applied  for  service  were  physically  unfit.  The  commission  ap- 
pointed to  inquire  into  the  reason  returned  the  verdict  that  malnu- 
trition of  children  was  one  of  the  most  serious  causes.  In  our  own 
country  at  the  beginning  of  the  recent  war  practically  the  same  situa- 
tion was  repeated.  Startlingly  large  numbers  of  applicants  had  to 
be  rejected  because  of  physical  unfitness,  and  again  the  consensus 
of  opinion  blamed  malnutrition  and  remediable  defects  of  infancy 
and  early  childhood. 

One  of  the  most  serious  results  of  malnutrition  is  shown  in  in- 
creased susceptibility  and  lack  of  resistance  to  disease.  Let  an  infec- 
tious disease,  such  as  measles,  whooping  cough,  or  scarlet  fever,  attack 
a  neighborhood  and  the  difference  between  the  well-nourished  and 
the  malnourished  child  at  once  appears.  The  child  in  fine  physical 
condition  may  not  escape  the  disease ;  but  if  he  does  contract  it,  he  has 
more  vigor  to  withstand  the  attack  and  his  recovery  is  usually  rapid. 
The  undernourished  child,  on  the  other  hand,  especially  if  he  has 
bad  teeth,  diseased  tonsils,  or  adenoids,  usually  "takes"  the  disease, 
probably  has  a  more  serious,  case,  and  recovers  with  greater  difficulty, 
if  at  all.  A  large  proportion  of  mortality  among  children  is  due 
directly  or  indirectly  to  faulty  nutrition.  Scarlet  fever,  diphtheria, 
measles,  pneumonia,  tuberculosis,  and  intestinal  diseases  claim 
most  of  their  victims  from  those  who  have  not  sufficient  stamina  to 
resist  them. 

The  relation  between  malnutrition  and  tuberculosis  needs  special 
emphasis.  We  have  seen  that  tuberculosis  may  be  an  active  cause  of 
malnutrition,  and  we  now  find  that  a  malnourished  body  is  the  best 
soil  for  tuberculosis.  It  is  a  vicious  circle.  Malnutrition  makes  the 
child  susceptible  to  tuberculosis,  which,  once  started,  tears  down  the 
body  and  increases  the  degree  of  undernutrition.  This  in  turn  makes 
the  progress  of  the  disease  still  easier,  and  thus  the  process  continues 
until  the  end.  The  only  possible  way  to  withstand  tuberculosis,  once 
infection  has  occurred,  is  to  build  up  so  fine  and  well-nourished  a 
body  that  the  disease  can  make  no  headway. 

If  mothers  could  be  taught  to  regard  undernutrition  as  an  abnormal 
condition,  likely  to  result  at  any  time  in  serious  illness  and  possible 
death,  they  could  be  more  easily  persuaded  to  strain  every  effort  to 
bring  their  children  up  to  normal,  and  they  would  cease  to  take  pride, 
as  do  many  mothers  even  yet,  in  having  a  "  delicate  "  child. 

MENTAL  EFFECTS. 

The  effect  of  nutrition  on  mental  development  has  long  been  recog- 
nized. There  has,  indeed,  been  shown  to  be  a  close  relation  between 
malnutrition  and  backwardness  in  school.  Experiments  in  school 
feeding,  both  here  and  abroad,  have  shown  that  an  improvement  in 
the  nutrition  of  a  child  is  in  practically  all  cases  accompanied  by 


14 

mental  improvement  also.  Teachers  testify  that  the  children  are 
easier  to  teach,  have  greater  power  of  concentration  and  attention, 
and  are  able  to  do  better  work,  as  is  shown  by  their  school  grades. 
This  is  not  difficult  to  understand,  for  a  starved  brain  can  not  be 
expected  to  work  efficiently  any  more  than  can  a  starved  body.  It 
is  not  surprising,  therefore,  to  find  considerable  retardation  in  mal- 
nourished children. 

Dr.  Tredgold,  ©  one  of  the  leading  authorities  on  mental  defi- 
ciency, tells  us  that  in  some  cases  this  retardation  due  to  malnutrition 
may  be  so  extreme  as  to  make  it  almost  impossible  to  distinguish  it 
from  actual  mental  defect.  That  it  is  not  so  is  shown  by  the  rapidity 
with  which  the  child  becomes  mentally  normal  when  the  adverse 
factors  causing  the  subnormal  physical  condition  are  removed.  Dr. 
Tredgold  believes  it  possible,  however,  for  malnutrition  to  be  so 
severe  and  prolonged  that  a  degree  of  actual  mental  deficiency  of 
secondary  form  may  be  produced.  Such  cases  he  admits  are  very 
uncommon,  but,  since  he  has  had  a  number  of  cases  in  which  no  other 
cause  could  be  assigned,  he  holds  to  the  opinion  that  they  may  occur. 

It  is  thus  seen  to  be  imperative  from  the  standpoint  of  the  mental 
as  well  as  the  physical  welfare  of  the  race  that  every  means  should 
be  used  to  make  and  keep  the  rising  generation  physically  sound  and 
well  nourished. 

TREATMENT  OF  MALNUTRITION. 

The  first  step  in  the  treatment  of  malnutrition  is  to  find  the  cause. 
This  means  a  careful  inquiry  into  the  child's  whole  method  of  living, 
as  well  as  a  thorough  standardized  physical  examination.  (§)  The 
cause  discovered,  the  next  step,  obviously,  is  to  remove  it.  Some- 
times this  is  a  comparatively  simple  matter,  and  again  the  child's 
whole  program  of  life  needs  to  be  thoroughly  overhauled.  Tonsils 
and  adenoids  may  need  to  be  taken  out,  bad  teeth  cared  for,  the  diet 
regulated,  and  a  new  scheme  of  living  instituted.  If  poverty  is  a 
determining  factor,  the  help  of  relief  agencies  must  be  enlisted; 
ignorance  of  the  requirements  of  adequate  food  and  healthful  living 
must  be  replaced  by  knowledge;  and  parents  urged  to  exercise  a 
wiser,  firmer  control  of  their  children's  way  of  living.  To  do  all 
these  requires  a  program  of  health  education  and  sometimes  even  the 
provision  of  opportunities  for  securing  proper  food  and  living  in  the 
fresh  air.  Some  of  the  agencies  which  have  been  established  to  meet 
these  needs  are  discussed  in  the  following  sections. 

SCHOOL  LUNCHES.     @ 

School  lunches  were  established  in  England  almost  immediately 
following  the  discovery  in  1900  of  the  extent  of  malnutrition  in  that 
country  (discussed  on  p.  13),  and  have  been  extensively  used  there. 
During  the  year  1914r-15,  a  maximum  number  of  29,560,316  meals 


15 

were  served  by  the  educational  authorities.  <§)  These  lunches  are 
of  the  extra  meal  type,  sometimes  being  a  breakfast,  sometimes  a  mid- 
morning  lunch,  and  again  only  a  cup  of  milk.  They  minister  largely, 
though  not  entirely,  to  the  children  of  the  poor,  and  their  use  is  based 
on  the  belief  that  insufficient  food  is  the  chief  cause  of  poor  nutrition. 
The  results  of  school  feeding  in  England  have  been  so  beneficial  to 
the  children  in  every  way  that  the  school  lunch  as  a  specific  measure 
for  dealing  with  malnutrition  has  become  a  firmh7  established  in- 
stitution. 

The  American  school  lunch  is  of  two  types.  One,  like  the  Eng- 
lish, is  the  midmorning  lunch,  meant  to  supplement  the  scanty  break- 
fasts which  so  large  a  number  of  children  have,  and  to  provide  extra 
nourishment  which  often  seems  to  be  necessary  in  order  to  cause 
underweight  children  to  make  proper  gains.  New  York,  Phila- 
delphia, Chicago,  and  other  cities  have  started  lunches  of  this  kind, 
but  even  in  these  cities  only  a  beginning  has  been  made.  The  chil- 
dren pay  for  their  lunches  for  the  most  part,  but  provision  is  also 
made  for  those  who  are  unable  to  do  so. 

The  other  type  is  the  hot  midday  lunch  which  is  provided  for  chil- 
dren whose  mothers  are  away  from  home,  who  live  too  far  from 
school,  or  who  for  other  reasons  are  unable  to  go  home  at  noon. 
These  lunches  are  being  widely  introduced  thoughout  the  country. 
''Special  impetus  has  been  given,  the  last  few  years,  to  the  movement 
of  supplying  a  hot  noon  meal  for  children  of  the  rural  schools  also. 

It  can  not  be  doubted  that  both  types  of  lunch  have  been  factors 
in  improving  the  condition  of  children.  It  is  true,  however,  that  the 
school  lunch  has  never  done  as  much  as  it  could  and  should  do.  Chil- 
dren, for  the  most  part,  choose  their  food  unsupervised  and  thus  too 
often  have  lunches  inadequate  in  amount  and  unsuitable  in  kind,  in 
spite  of  the  fact  that  the  school  provides  them.  There  is  need  that 
the  school  lunch  should  be  recognized  and  used  as  one  of  the  school's 
greatest  opportunities  for  health  instruction.  Dr.  Emerson  has  de- 
cided from  his  experience  that  a  malnourished  child  can  use  food 
given  in  five  small  meals  much  better  than  if  the  same  amount  of  food 
is  given  in  three  meals. 

FRESH-AIR  CLASSES  OR  SCHOOLS. 

In  the  United  States  open-air  rooms  and  schools  have  been  em- 
ployed for  a  number  of  years  for  tuberculous  children,  but  of  recent 
years  they  are  being  used  for  malnourished  children  to  some  extent. 
With  nourishing  food,  fresh  air,  and  physical  and  mental  work 
suited  to  their  condition,  it  is  needless  to  say  that  the  gain  of  these 
children  in  all  respects  is  usually  striking. 

Dr.  Newman  ®  in  1917  expressed  regrot  that  provision  for  edu- 
cation under  these  open-air  conditions  had  not  increased  more  rapidly. 


16 

He  urged  strongly — what  could  be  equally  well  recommended  for  the 
United  States — that  more  of  these  schools  be  established  for  the  mal- 
nourished children  of  Great  Britain. 

NUTRITION  CLINICS  AND  CLASSES. 

One  of  the  most  effective  methods  of  dealing  with  undernutrition 
is  the  malnutrition  clinic,  or,  as  it  is  better  called,  the  nutrition  class. 
Dr.  Emerson  (§)  as  long  ago  as  1910  was  conducting  such  a  class  in 
Boston,  and  more  recently  others  0  (§)  ®  <g)  <§)  @  @  have  been 
started  in  New  York  City,  while  scattering  ones  are  reported  in  a 
few  other  cities.  (§)  Briefly,  the  conduct  of  a  malnutrition  class  is 
as  follows:  ®  (§) 

Groups  of  underweight  children  meet  weekly  to  be  weighed,  are 
examined  by  a  physician,  and  given  class  instruction  in  food  values 
and  hygiene.  Weight  charts  are  kept  (see  p.  IT),  and  the  children 
compete  to  see  which  can  gain  most  or  be  first  to  reach  the  normal 
weight  lines.  Any  physical  defects,  such  as  diseased  tonsils  and  ade- 
noids, are  always  cared  for  first,  as  no  gain  can  be  expected  until 
these  causes  are  removed.  Visits  to  the  home  to  study  home  condi- 
tions and  to  engage  the  interest  of  the  parents  in  carrying  out  the 
classroom  instruction  are  a  necessary  and  valuable  part  of  the  work. 
Mothers  are  urged  to  come  to  the  class,  but  the  instruction  is  given 
primarily  to  the  children.  The  cooperation  of  the  child  is,  in  fact, 
the  biggest  factor  in  the  success  of  the  class.  Once  a  boy  becomes 
interested  in  his  weight  curve,  he  will  drink  milk,  eat  vegetables  and 
oatmeal,  go  to  bed  earlier,  open  his  windows,  and  take  the  necessary 
rest  periods — things  his  parents  may  have  been  almost  powerless  to 
get  him  to  do.  The  repeated  health  instructions,  together  with  the 
weekly  checking  up  and  the  spirit  of  class  competition,  combine  to 
produce,  on  the  whole,  excellent  results.  Many  of  the  children  make 
almost  startling  gains  and  most  of  them  gain  at  more  than  the  ex- 
pected rate. 

There  is  general  agreement  that  this  type  of  work  should  be  ex- 
tended. Classes  need  not  be  confined  to  the  dispensaries  where  they 
started,  but  may  be  conducted  in  schools,  settlement  houses,  day 
nurseries — any  place  where  children  are  gathered  together.  The 
school  is  the  logical  place  for  this  health  instruction.  Here  regu- 
larity of  attendance  can  be  easily  secured;  and  the  combined  efforts 
of  the  medical  service,  hygiene  classes,  the  physical  training  exer- 
cises, the  domestic  science  department,  and  the  school  lunch,  as  well 
as  the  general  school  activities,  can  all  be  utilized  to  insure  that  all 
the  children  learn  and,  during  the  school  day  at  least,  practice  health- 
ful, hygienic  living.  Chicago  has  just  started  a  city-wide  campaign 
of  this  ^nature  in  its  public  schools.  The  field  has  been  surveyed, 
scales  for  every  building  have  been  purchased,  and  the  work  is 
already  begun  in  a  few  schools.  It  is  to  be  hoped  that  this  movement 
will  soon  be  nation  wide. 


17 


SPECIMEN    CHART    KEPT    FOR    EACH    CHILD    UNDER   TREATMENT  BY 

THE  CLASS  METHOD.1 


ROBERT  M« 


Red  star,  represented  by^,  means  daily  lunch;  blue  star,  represented  by 
0,  means  daily  rest  period;  gold  star,  represented  by  f,  means  greatest 
gain  in  week.  The  weight  curve  is  that  of  a  child  chosen  because  he  was 
under  constant  observation  day  and  J&ht,  together  with  11  other  children,  all 
of  whom  lost  weight  on  these  same  dates  when  lunches  and  rest  periods  were 
omitted  the  week  preceding.  On  the  original  chart  the  weight  curve  is  in 
red.  Diagnosis  of  the  cause  of  gain  or  loss  in  weight  of  children  in  the  school 
could  be  made  by  inference  only,  and  therefore  could  not  be  verified. 


1  Prepared  by  Dr.  Wm.  R.  P.  Emerson  and  published  in  an  article  by  him  on  "  A  nutri- 
tion clinic  in  a  public  school,"  in  the  American  Journal  of  Diseases  of  Children,  vol.  17 
(April,  1919),  p.  260. 


18 
CHILDREN'S  YEAR  CAMPAIGN. 

The  agencies  already  referred  to  have  been  concerned  only  with 
the  child  of  school  age.  It  is  during  the  preschool  period,  however, 
that  malnutrition  usually  starts.  The  Children's  Bureau  by  this 
past  year's  campaign  for  children  of  preschool  age  has  at  last  cen- 
tered the  attention  of  the  country  upon  this  "the  neglected  age." 
The  program  for  Children's  Year  which  the  bureau  outlined  has 
been  carried  out  by  the  local  child  welfare  committees  organized  under 
the  Child  Conservation  Section  of  the  Council  of  National  Defense. 
Through,  weighing  and  measuring  tests  and  conferences  on  child 
welfare,  an  enormous  number  of  children  has  been  reached.  Greater 
even  than  this  work,  however,  will  be  that  which  States,  cities, 
social  organizations,  physicians,  and  parents  have  been  roused  to  do. 
Some  cities  have  instituted  a  house-to-house  canvass  to  examine  chil- 
dren for  malnutrition,  diseased  tonsils,  adenoids,  and  other  defects, 
and  a  movement  to  extend  the  work  of  infant-welfare  centers  to 
children  of  this  group  has  already  begun. 

Adequate  prenatal  care  is  becoming  more  and  more  general ;  babies 
up  to  2  years  of  age  are  for  the  most  part  looked  after  either  by 
private  physicians  or  infant- welfare  societies.  When  all  infant-wel- 
fare agencies  assume  responsibility  for  the  preschool  child ;  when  all 
schools,  through  proper  medical  attention,  health  instruction,  school 
lunches,  and  healthful  schoolroom  conditions,  insure  suitable  ca*re 
of  the  school  child ;  then  the  ideal — continuous  health  supervision  of 
children  from  conception  through  all  the  growing  period — will  come 
near  to  being  realized.  Then,  and  not  till  then,  can  we  hope  to  solve 
the  problem  of  the  undernourished  child. 


REFERENCES. 

©    Newman,   George,  M.   D. :   Annual    Report  of  the  Chief  Medical   Officer, 

Board  of  Education   (England  and  Wales),  1915-16,  p.  32. 
©    Ibid.,  1912-13,  p.  26. 
®    Emerson.  Wra.  R.  P.,  M.  D. :  "  Foad  habits  of  delicate  children,"  in  New 

York  Medical  Journal,  vol.  105,  1917,  p.  361. 
©    -          -  "A  nutrition  clinic  in  a  public  school,"  in  American   Journal  of 

Diseases  of  Children,  vol.  17,  1919,  p.  251. 
©    Holt,  L.  Emmett,  M.  D. :  Discussion  :  "  Standards  for  growth  and  nutrition 

of  school  child,"  in  Archives  of  Pediatrics,  vol.  35,  19.^8,  p.  3.",!). 
©    -         -  "Standards  for  growth  and  nutrition,"  in  American   Journal  of 

Diseases  of  Children,  vol.  16,  1918,  p.  359. 
©    Newman,   George,  M.    D. :   Annual   Report  of  the  Chief  Medical    Officer, 

Board  of  Education  (England  and  Wales),  1917-18,  p.  126. 
©    Ibid.,  1915-10,  p.  142. 
®    Ibid.,  1917-18,  p.  8. 

@    Chapin,  Henry  D.,  M.  D. :  "  The  national  danger  from  defective  develop- 
i*-  of  growing  children  in  time  of  war,"  in  Medical  Record,  vol.  93, 

89. 
@  ;  attrition  among  school  children,"  in  Weekly  Bulletin  of  the  Depart- 

r  of  Health,  City  of  New  York,  vol.  7,  March  9,  191S.  p.  75. 
y,  Frank  A. :   "A  scale  for  marking  malnutrition,"  in   School   and 
Society,  vol.  3,  1916,  p.  123. 

-  "A  comparison  of  three  methods  of  determining  defective  nutri- 
Jtion,"  in  Archives  of  Pediatrics,  vol.  35,  1918,  p.  88. 

•Baker,  S.  Josephine,  M.  D. :  "  The  relation  of  war  to  the  nourishment  of 
«  children,"  in  New  York  Medical  Journal,  vol.  107,  1918,  p.  289. 
Wood,  Thomas  D.,  M.  D. :  War's  Emphasis  on  Health  Education  (address 
3  before  the  National  Council  of  Education,  February  28,  1918,  published 

in  the  New  York  Times,  April  14,  1918). 

®    McCollum,  E.  V. :   "The  supplementary  dietary  relationships  among  our 
natural  foodstuffs,"  in  Journal  of  American  Medical  Association,  vol.  68, 
1917,  p.  1379. 
Tredgold,  A.  F. :  Mental  Deficiency.     William  Wood  &  Co..   New   York, 

1914,  pp.  291-295. 
i    Emerson,  Wm.  R.  P.,  M.  D. :  "Standardized  physical  examinations."  in 

Archives  of  Pediatrics,  vol.  35,  1918,  p.  411. 

liryant,   Louise  S. :   School  Feeding.     J.  B.  Lippincott  Co.,  Philadelphia, 
?  1913,  p.  147. 
(§)    Newman,   George,  M.   D. :   Annual  Report  of  the  Chief  Medical   Officer, 

Board  of  Education  (England  and  Wales),  1917-18,  p.  128. 
Ibid. :  pp.  92-93. 
Kind-son,  Wm.  R.  P.,  M.  D. :   "Class  methods  in  dietetic  and  hygienic     ^ 

treatment  of  delicate  children,"  in  Pediatrics,  vol.  22.  1910,  p.  626. 
(a)    Public  health  committee,  New  York  Academy  of  Medicine:  "Malnutrition 
among  school  children,"  in  Medical  Reco-d.  vol.  03,  191S.  p.  311. 

(19) 


20 


Smith,  Charles  Henclge,  M.  D. :  "  Methods  used  in  a  class  for  under- 
nourished children, """in  American  Journal  of  Diseases  of  Children,  vol. 
15,  1918,  p.  373. 

Kantor,  John  L.,  M.  D. :  "  Experience  with  a  class  in  nutrition,"  in  New 
York  Medical  Journal,  vol.  108,  1918,  p.  241. 

Wilson,  May  G.,  M.  D. :  "Report  of  the  Cornell  nutrition  class,"  in  Ar- 
chives of  Pediatrics,  vol.  36,  1919,  p.  37. 

Manny,  Frank  A. :  "  Nutrition  clinics  and  classes,"  in  Modern  Hospital, 
vol.  10,  1918,  p.  129. 

Mitchell,  David,  M.  D. :  "  Malnutrition  and  health  education,'"  in  Peda- 
gogical Seminary,  vol.  26,  1919,  p.  1. 

Roberts,  Lydia :  "  A  malnutrition  clinic  as  a  university  problem  in  ap- 
plied dietaries,"  in  Journal  of  Home  Economics,  vol.  11,  1919,  p.  95. 

Smith,  Charles  Hendee,  M.  D. :  How  to  Conduct  a  Nutrition  Class.  Child 
Health  Organization,  289  Fourth  Avenue,  New  York. 


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